<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 345002940
Report Date: 12/14/2023
Date Signed: 12/14/2023 04:01:37 PM


Document Has Been Signed on 12/14/2023 04:01 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827



FACILITY NAME:MADISON SQUARE SENIOR LIVING IIFACILITY NUMBER:
345002940
ADMINISTRATOR:DARIUS O. STIRFACILITY TYPE:
740
ADDRESS:3120 COLORADO ST.TELEPHONE:
(916) 757-0918
CITY:CARMICHAELSTATE: CAZIP CODE:
95608
CAPACITY:6CENSUS: 4DATE:
12/14/2023
TYPE OF VISIT:POCUNANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:Darius StirTIME COMPLETED:
03:00 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
On 12/14/2023, Licensing Program Analyst (LPA) Cassie Yang arrived unannounced at the facility to conduct a Plan of Correction (POC) visit for deficiencies issued on 12/06/2023. LPA met with Administrator, Darius Stir, and explained the purpose of the visit.

During visit of 12/06/2023, LPA cited the facility four (4) type A deficiencies. LPA explained all type A violations have POC due date within 24 hours, on 12/07/2023.

- 87309 Storage Space
- 87202 Fire Clearance
- §1569.17 Fingerprints and criminal records of individuals in contact with clients; exemptions; criminal records clearances
- §1569.618 Administration and management of residential care facilities

LPA received an email from Administrator at 12AM on 12/08/2023, with the requested POC's.

Today's visit, civil penalties are assessed for failure to correct of $100 per day.

Exit interview and a copy of the report and appeal rights provided.
SUPERVISOR'S NAME: Anthony PerezTELEPHONE: (323) 485-4915
LICENSING EVALUATOR NAME: Cassie YangTELEPHONE: (916) 201-1928
LICENSING EVALUATOR SIGNATURE:
DATE: 12/14/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/14/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 1